Child's Name: ______________________________
Date of Birth: _______________________________
Parent/Guardian Names: ______________________
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Home Telephone: ____________________________
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Work Telephone: ____________________________
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Address: __________________________________
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Important Health Problems/Allergies: _____________
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Medications Taken Regularly: ___________________
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Doctor Names and Phone Numbers: ______________
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Dentist's Name and Phone Number: ______________
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Health Insurance Numbers: _____________________
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Pharmacy Names and Phone Numbers: ___________
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Poison Control Center Number: 1-800-222-1222
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The Pocket Guide to Good Health for Children